Accepted Manuscript

Title: MORTON’S INTERDIGITAL NEUROMA OF THE

FOOT

Authors: Francesco Di Caprio, Renato Meringolo, Marwan

Shehab Eddine, Lorenzo Ponziani

PII: S1268-7731(17)30034-6
DOI: http://dx.doi.org/doi:10.1016/j.fas.2017.01.007
Reference: FAS 1000

To appear in: Foot and Ankle Surgery

Received date: 26-9-2016

Revised date: 15-11-2016
Accepted date: 27-1-2017

Please cite this article as: Di Caprio Francesco, Meringolo Renato, Shehab Eddine
Marwan, Ponziani Lorenzo.MORTON’S INTERDIGITAL NEUROMA OF THE
FOOT.Foot and Ankle Surgery http://dx.doi.org/10.1016/j.fas.2017.01.007

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MORTON’S INTERDIGITAL NEUROMA OF THE FOOT

A literature review

Francesco Di Caprio, Renato Meringolo, Marwan Shehab Eddine, Lorenzo Ponziani.

Operating Unit of Orthopedics and Traumatology, AUSL of Romagna, Ceccarini Hospital, Riccione

47838 (Italy)

Corresponding author: Francesco Di Caprio, MD, U.O. Ortopedia e Traumatologia, Ospedale

Ceccarini, Viale Frosinone, 47838, Riccione (RN), Italy

francesco.dicaprio@auslromagna.it

Telephone: +39-0541-608839

Fax: +39-0541-608837

Highlights

 The diagnosis of Morton's neuroma is clinical.

 Conservative treatment effective in 30% of cases, to avoid or delay surgery.

 Longitudinal dorsal approach havesuccess rates of 51% to 85%.

 Plantar approach is related with scar problems and delayed full weight bearing.

 Plantar approach showed better results for surgical treatment of recurrent neuroma.

Abstract

Morton's neuroma is one of the most common causes of metatarsalgia. Despite this, it remains

little studied, as the diagnosis is clinical with no reliable instrumental diagnostics, and each study
1
may deal with incorrect diagnosis or inappropriate treatment, which are difficult to verify. The

present literature review crosses all key points, from diagnosis to surgical and nonoperative

treatment, and recurrences.

Nonoperative treatment is successful in a limited percentage of cases, but it can be adequate in

those who want to postpone or avoid surgery. Dorsal or plantar approaches were described for

surgical treatment, both with strengths and weaknesses that will be scanned.

Failures are related to wrong diagnosis, wrong interspace, failure to divide the transverse

metatarsal ligament, too distal resection of common plantar digital nerve, an association of tarsal

tunnel syndrome and incomplete removal. A deep knowledge of the causes and presentation of

failures is needed to surgically face recurrences.

Keywords

Morton; Civinini; Interdigital neuroma; Metatarsalgia

INTRODUCTION

Morton's neuroma is a very common cause of metatarsalgia, and consists in an interdigital nerve

disease of the foot, classically located at the third intermetatarsal space.

Despite its high incidence, Morton’s neuroma was little studied. For this reason we performed this

literature review, with the first author being involved in literature search, paper drawing up,

introduction and diagnostics. The second author in surgical treatment. The third in conservative

and infiltrative treatment. The fourth in discussion and final supervision.

Interdigital neuroma is a clinical syndrome of the forefoot which has often been described in the

last two centuries. It was first reported by Civinini [1,2] in 1835 and later by Durlacher in 1845 [3],
2
who described the clinical complex of symptoms. Thomas George Morton described “a peculiar

and painful affection of the fourth metatarsophalangeal articulation” in 1876 [4,5]. He attributed

the pain to the fourth metatarsophalangeal joint. It was Hoadley who first actually excised an

interdigital neuroma from the third webspace of a foot in 1883 [6].

Morton's neuroma prefers the female sex, with a female:male ratio of 4:1 [7], with an average age

of 50 years at surgery [8]. The neuroma is bilateral in 21% of cases, it affects third space in 66% of

cases, the second in 32%, and the fourth in 2% [8]. Multiple locations are rare [9].

The most common symptom is a burning pain in the plantar aspect of the foot, located between

the metatarsal heads, often radiating to the two corresponding toes. Sometimes the patient

reports a shooting sensation on the plantar side, associated with sharp pain. Occasionally the pain

radiates proximally along the plantar or dorsal surface of the foot. The pain is exacerbated when

the patient is wearing a tight shoe or a heel, which is why the patient is forced to remove the shoe

and massaging the foot. The patient may report a sensation of numbness in the toes or shock

sensation.

Below the medial malleolus of the tibial nerve divides into two plantar branches, medial and

lateral. These are distributed to the sole up to the intermetatarsal spaces. In particular, the medial

plantar nerve is divided into the own digital hallux nerve and the common digital nerves for first,

second and third interspace, while the lateral plantar nerve form the own digital nerve for the fifth

toe and the common digital nerve for the fourth interspace. An anastomotic branch, present in

66.2% of cases, arises from the common digital nerve for the fourth interspace, passing below the

fourth metatarsal, in communication with the common digital nerve to the third interspace,

whereby the latter is formed by an anastomosis between branches from both nerve trunks [10].

Each interdigital nerve passes below the corresponding distal metatarsal transverse ligament

3
(DMTL), which is just proximal to the metatarsal heads, and then divides into the two digital

nerves.

Morton's neuroma [11] consists of a bulge in the interdigital nerve just distal to the DMTL, and

before the bifurcation in the digital nerves (Fig. 1). Macroscopically it has a typically fusiform

configuration, a glistening and white to yellowish appearance and a relatively soft consistency.

Histological findings include neural degeneration, epineural and endovascular hyalinization, and

perineural fibrosis [12-14].

It was suggested that the common digital nerve to the third interspace is thicker than the others,

as it results from an anastomosis between branches from the two nerve trunks [15-17]. Another

anatomical factor is the increased mobility of the fourth radius (moving on the cuboid), compared

to the third (fixed to the cuneiform). Some believe that taut DMTL play a critical role in

compressing the interdigital nerve [12]. In this sense, the use of high heels is another predisposing

factor since the extension of the metatarsophalangeal forces the digital nerve just beneath the

DMTL [1,17,18]. This latter theory was debated on the basis of anatomical studies [19] and imaging

[20].

Some studies described the relationship with trauma [21,22].

DIAGNOSIS

The diagnosis of Morton's neuroma is eminently clinical [23-25]. It's important to accurately locate

the pain. In fact, patients with Morton's neuroma do not experience pain on the metatarsal heads.

In the latter case it will be important to highlight the forefoot deformities, instability or arthritis in

the metatarsophalangeal joint, Frieberg’s disease.

Clinically there may be tenderness and a dorsal bulging may be found. It may also be present an

enlargement of the interdigital space. When pressure is applied axially to the intermetatarsal space

acute pain is induced. The pressure can be exerted while tightening the metatarsals with the other
4
hand, and this may be associated with a painful and palpable clicking sensation (Mulder’s sign)

[25]. This test demonstrated a 94-98% sensitivity [26-28].

X-rays are essential to investigate other causes of metatarsalgia [29,30] (metatarsal hypermetria,

tarsal-metatarsal joint stiffness, Frieberg's disease, toe deformities, metatarsal-phalangeal

instabilities).

Ultrasound and MRI have always been considered not reliable in the diagnosis of Morton's

neuroma [13,26,31-34]. The MRI recently showed a sensitivity 93% with specificity 68%, while the

ultrasound sensitivity was 90% and specificity 88% [35]. Ultrasound, even in highly skilled hands,

has a high rate of incidental finding of an asymptomatic interdigital nerve enlargement, which can

lead to a false diagnosis of a Morton's neuroma. Moreover small lesions are difficult to diagnose by

imaging, but are still able to cause symptoms as larger lesions [32,33]. Clinical examination is still

the gold standard for the diagnosis of a Morton's neuroma [32,33].

There is no absolute requirement for imaging patients who clinically have a Morton's neuroma.

The two main indications for imaging are (a) an unclear clinical assessment and (b) cases when

more than one web space is affected. Ultrasonography should be the investigation of choice [28].

On the contrary, The MR imaging diagnosis of Morton's neuroma does not imply symptomatology.

Careful correlation between clinical and MR imaging findings is mandatory before Morton's

neuroma is considered clinically relevant [30].

The use of local infiltration with 2 ml of lidocaine below the intermetatarsal ligament instead has a

high diagnostic value because it causes temporary pain relief.

CONSERVATIVE TREATMENT

Conservative treatment consists in the use plantar orthosis with metatarsal unloading. The use of

steroid infiltrations provides a long-term resolution of symptoms in a small percentage of cases

(30%) [36-38]. Some authors reported that injections provided complete pain relief in
5
approximately 30% of patients, and partial relief in 30-50% [36,39]. After two years nearly 95% of

those patients with initial complete pain relief remained asymptomatic [36]. Better long-term

results were demonstrated for smaller neuromas [40].

Steroid infiltrations are repeatable only in a limited way as they can lead to atrophy of the plantar

fat pad, skin discoloration at the injection site [41], rupture of the metatarsophalangeal joint

capsules with deviation of adjacent toes. In 60-70% of cases the patients still decide to undergo

surgical treatment. One study compared the results of conservative and surgical treatment of

Morton’s neuroma and as the result the authors recommended surgical treatment as initial

treatment [42]. However, the infiltrative treatment is believed to be indicated in those who want to

try to avoid surgery, or to delay surgery due to business or sporting engagement.

In the recent years, new treatment strategies were studied. Botulinum toxin A already

demonstrated analgesic effects in epicondilitis, low back pain, piriformis syndrome [43] and plantar

fascitis [44], and also in neuropathic pain [45]. The analgesic effects of the toxin may be related to

inhibition on neuropeptide release in nociceptive terminals [46]. A recent study about Botulinum

toxin A in the treatment of Morton’s neuroma demonstrated improvements in 70.6% of patients 3

months after a single injection, with no adverse effects [47]. Long-term results are lacking.

Alcohol injections also demonstrated improvements in 69-90% of cases [47,48,49], and a 30%

decrease in the size of the neuroma [48,50]. This treatment is repeatable, but a transitory increase

in pain occurred in 15% of patients [48]. Long-term results however demonstrated a deterioration,

with approximately one third of patients undergoing surgery, one third with pain recurrence, and

only one third remaining pain free at five years follow-up [51].

Infiltrative treatment can also use ultrasound guidance [47,52-55], even if this strategy failed to

demonstrate better results compared with non-guided injections [56].

6
Other conservative treatment methods include radiofrequencies [57-60], extracorporeal

shockwave therapy [61,62], laser therapy [63,64], homeopathic injections [65].

SURGICAL TREATMENT

Surgical excision of Morton's neuroma must provide for the common digital nerve resection as

proximal as possible, with the proximal stump embedded in the context of the intrinsic muscles, to

avoid an eventual amputation neuroma placed below the metatarsal heads. It is necessary to avoid

removing large amounts of fat tissue to prevent the scarring and then the atrophy of the plantar

pad.

The surgical approach may be dorsal [66-69] or plantar [23,70,71]

A longitudinal dorsal approach centered on the interspace (Fig. 2) is the preferred by most

surgeons, and it was first described by McElvenny in 1943 [72]. The advantages of a dorsal

approach as compared to plantar approach are claimed to be as follows [12,73]: (1) The ability to

release the DMTL; (2) The dorsal incision being in the non-weight bearing surface of the foot,

allows for early rehabilitation; (3) It provides a good overview interspace and allows to follow the

nerve proximally; (4) The plantar cutaneous nerves are easier to find and excise through dorsal

approach as compared to plantar approach where dissecting the nerves in plantar fatty tissue can

be difficult.

A longitudinal plantar approach (Fig. 3) must be performed exactly below the intermetatarsal

space to avoid the scar to affect the loading portion. In addition, the incision must be thorough

with resolution through the fat pad to prevent the dissection [74,75]. It’s possible to perform a

transverse plantar approach (Fig. 4) just proximal to the flexion skin fold [70,76]. This prevents

approach to the load portion, but it must be extended to the adjacent spaces, with significant

dissection, possible atrophy of the fat pad, and difficulty following the nerve proximally [12].

7
The advocates of plantar approach believe that this approach is safe, they do not believe that there

is need to release the DMTL; they believe that the DMTL is not contributing to neuroma formation

and that its release predisposes to metatarsalgia by metatarsal splaying [20,73].

Nevertheless one study revealed that DMTL transection does not increase the intermetatarsal

angle or the risk of splayfoot development. Moreover, transection is recommended due to an

enhanced overview during surgery and better clinical outcome [77].

An endoscopic decompression of the interdigital nerve through DMTL release was also described,

with overall good results, low rate of complications, and no loss of sensitivity [78-82]. One study

indicated neurolysis by DMTL release in the cases of compression symptoms without macroscopic

changes in the nerve, with results similar to neurectomy [83]. But no comparative studies between

neurectomy and decompression exist.

Percutaneous treatment methods include metatarsal osteotomies associated with DMTL release.

One recent study [84] demonstrated short-term results comparable with neurectomy, but with

better long-term results.

Another study demonstrated better results with metatarsal shortening osteotomy associated with

DMTL release, compared with ligament release alone in the treatment of Morton’s Neuroma [85].

The success rate for neurectomy ranges from 51% to 85% in long-term follow-up studies

[8,23,66,67,70,73,86,87].

Postoperative wound infection, hematoma and scar problems were significantly higher in patients

having plantar approach as compared to those having dorsal approach [73]. Disorders related to

plantar scarring in the case of plantar longitudinal approach are reported in 5.2% of cases,

including delayed wound healing, hypertrophic scar formation, and inclusion cyst [74].

8
The delay to full weight bearing was significantly better for the dorsal approach [73]. No significant

differences were demonstrated in overall long-term results between dorsal and plantar approaches

[88].

Scoring results were significantly better in cases of single neuroma surgery, compared to multiple

neuroma excisions [8]. It remains unclear if the presentation of multiple neuromas itself is the

reason for a lower level of satisfaction, if multiple neuromas correlate with other underlying

forefoot pathologies, or if diagnosis of these multiple neuromas was correct at all. Previous reports

have cautioned against simultaneous exploration of adjacent interspaces, stating that the

occurrence of two neuromas in the same foot is rare and that the expected outcome is worse than

that after the exploration of one interspace [7,9,66,89]. Nevertheless other reports did not confirm

this hypothesis [87,90,91].

No difference was found comparing scoring results between patients who underwent neuroma

excision in second and third webspaces [8].

Comparing results of patients with or without transection of the deep intermetatarsal transverse

ligament showed slightly, but not significantly, better results for cases with transection of the deep

transverse ligament. Poor results were observed more often in cases without transection of the

deep transverse ligament [8].

A reduction of sensation or numbness in the supplying area of the resected nerve was detected in

72% of the feet [8,92]. The clinical outcome was not influenced by the level of sensibility [8]. The

pattern of numbness was quite variable and it was bothersome a limited percentage of cases (17%)

[73,92]. Sometimes the residual discomfort is described as the feeling of walking on cotton, or to

have the jammed sock under the foot. Only 63% of the patients are completely pain free at follow-

up [87].

9
The common digital artery accompanies the nerve, and it is resected along with the neuroma in

39% of cases. However this does not create disorders due to the presence of anastomotic networks

[93].

RECURRENT NEUROMAS

The failure rate of neurectomy was reported to be as high as 14% to 21% [73].

Recurrence of symptoms following interdigital neurectomy is believed to be due to wrong

diagnosis, wrong interspace, failure to divide the transverse metatarsal ligament, too distal

resection of common plantar digital nerve, an association of tarsal tunnel syndrome and

incomplete removal [66,72,75,94,95].

The review of recurrences [96-98] have shown that two thirds of patients showed symptoms within

12 months from the first surgery. In these cases it is likely that the problem had never been solved.

A third of the patients developed an amputation neuroma, which needs at least 12 months to

generate. In these cases it is likely that the cause is due to a resection not enough proximal.

The plantar branches prevents the nerve stump to retract proximally. They are concentrated in the

4 cm proximal to the intermetatarsal ligament. So a resection at that level, or more proximal,

ensures that the nerve can withdraw proximally [99].

Surgically facing a recurrent neuroma via dorsal approach needs expanding the incision of about 1

cm proximal to adequately expose the intermetatarsal space.

Plantar approach for recurrent neuroma showed better results in various studies

[12,20,72,90,94,96,97,100]. Other surgical improvements include release of the transverse

metatarsal ligament alone or in combination with neurolysis, and intermuscular transposition of

the transected nerve [94].

10
The results of surgical treatment of recurrent neuroma are not satisfactory in 20-40% of patients

[97]. Intra-operative findings, simultaneous surgery to adjacent interspaces, concomitant forefoot

surgery and previous re-explorations did not significantly influence the outcome. Persistent or

recurrent symptoms after transection of a nerve present a challenging problem for both the

surgeon and patient. It is essential that there is a thorough pre-operative discussion

with the patient, providing the rates of failure and the increased likelihood of restriction of

footwear and activity after revision surgery [91].

DISCUSSION

Morton's neuroma is a very common cause of metatarsalgia, and consists in an interdigital nerve

disease of the foot, classically located at the third intermetatarsal space.

When approaching a suspect of Morton’s neuroma (Fig. 5), medical history and physical

examination play a decisive role. It's important to let the patient talk, which often describe the

symptoms in a very suggestive way of Morton's neuroma. The foot examination should search for

the exact trigger point, distinguishing between metatarsal and intermetatarsal pain. In the latter

case it is essential to search the Mulder’s sign.

When we have a clinical certainty of neuroma Morton, it is not necessary to make use of any

instrumental examination. In fact ultrasound and MRI, even if with high sensitivity [35], are not

fully reliable for the diagnosis [32,33]. If in doubt about the diagnosis, use of imaging techniques

may raise further doubts, both in the surgeon and in the patient, which in case of negative test will

find it hard to believe the doctor's diagnosis and seek a second opinion. The most reliable method

to clarify the diagnosis is a local anesthetic injection. Unfortunately it is common for patients to
11
come to visit with these exams already available. There is often a discrepancy between the physical

findings and imaging, and in these cases the surgeon needs to explain to patients that these tests

are often misleading and that we must trust in the clinical examination giving indication for

surgery.

In case of metatarsal pain instead is necessary to examine other possible causes of metatarsalgia,

such as forefoot deformities, alterations in the metatarsal formula, tarsal-metatarsal stiffness,

metatarsal-phalangeal instabilities, Frieberg’s disease.

It is not impossible that the two issues are related, and for these cases combined techniques exist.

The weakness of this study is that a quality analysis of the papers was not performed, nor a

comparison of the results from the various studies in terms of AOFAS score or Foot Health Status

Questionnaire. A meta-analysis of the results was not in the purposes of this paper, which was

conducted in order to provide a comprehensive and updated overview of the present literature for

clinical guidance.

Plantar orthosis can be useful for conservative treatment. The use of steroid infiltrations provides a

long-term resolution of symptoms in 30% of cases, and it’s indicated in those who want to try to

avoid surgery, or to delay surgery due to business or sporting engagement. Alcohol injections

demonstrated results comparable with steroid injections, with the advantage of being repeatable,

even if with transitory increase in pain in 15% of patients. Other conservative methods include the

use of Botulinum toxin A and sclerosing agents. Ultrasound guidance recently failed to

demonstrate better results compared with non-guided injections [56].

Surgical excision of Morton's neuroma must provide for the common digital nerve resection as

proximal as possible, to avoid formation of an amputation neuroma placed below the metatarsal

heads. A longitudinal dorsal approach centered on the interspace is the preferred by most

surgeons, with success rates ranging from 51% to 85%. Plantar approach is related with scar
12
problems and delayed full weight bearing. No significant differences were found between dorsal

and plantar approaches in the long-term outcomes [88].

Recent studies [84,85] demonstrated the efficacy of metatarsal osteotomies associated with DMTL

release, compared to neurectomy. They found out that at long-term follow-up, patients operated

for neurectomy needed plantar orthoses due to plantar hyperpressure or bursitis. In our opinion a

correct diagnosis plays a key role in determining appropriate surgical indication. Morton’s diagnosis

is essentially clinical, and a lot of variables must be considered, such as alterations of metatarsal

formula, tarsal-metatarsal stiffness, etc... so that a strict mathematical association between

diagnosis of Morton’s neuroma and one single treatment is not possible. A residual metatarsalgia

after neurectomy may be due to scar tissue formation, inadequate removal of the neuroma, or

recurrence. Nevertheless it’s possible that a metatarsal overload was already present before

neurectomy, so that the indication to perform neurectomy alone was not correct. In conclusion a

correct diagnosis makes a correct treatment, and the treatment must be personalized.

Failure rates of surgical treatment were reported to be as high as 14% to 21%. Plantar approach

showed better results for surgical treatment of recurrent neuroma. However revision surgery failed

to provide excellent results, and this must be discussed with the patients.

Conflicts of interest

This research did not receive any specific grant from funding agencies in the public, commercial, or

not-for-profit sectors.

REFERENCES

1. Civinini F. Su d’un nervoso gangliare rigonfiamento alla pianta del piede. Lettera anatomica al

Dr. Salomone Lampronti, Pistoia: Tip. Bracali; 1835.

13
2. Pasero G, Marson P. [Filippo Civinini (1805-1844) and the discovery of plantar neuroma].

Reumatismo 2006;58(4):319-22.

3. Durlacher L. Treatise on corns, bunions, the diseases of nails and the general management of

the feet. London: Simpkin-Marshall; 1845.

4. Morton TG. A peculiar and painful affection of the fourth metatarso-phalangeal articulation.

Am J Med Sci 1876;71:37–45.

5. The Classic. A peculiar and painful affection of the fourth metatarso-phalangeal articulation.

Thomas G. Morton, M.D. Clin Orthop Relat Res 1979;(142):4-9.

6. Hoadley A. Six cases of metatarsalgia. Chicago Med Rec 1893;5:32.

7. Bradley N, Miller WA, Evans JP. Plantar neuroma: analysis of results following surgical excision

in 145 patients. South Med 1976;69(7):853-4.

8. Kasparek M, Schneider W. Surgical treatment of Morton's neuroma: clinical results after open

excision. Int Orthop 2013;37(9):1857-61.

9. Thompson FM, Deland JT. Occurrence of two interdigital neuromas in one foot. Foot Ankle

1993;14(1):15-7.

10. Frank PW, Bakkum BW, Darby SA. The communicating branch of the lateral plantar nerve: a

descriptive anatomic study. Clin Anat 1996;9(4):237-43.

11. Graham CE, Graham DM. Morton's neuroma: a microscopic evaluation. Foot Ankle

1984;5(3):150-3.

12. Alexander IJ, Johnson KA, Parr JW. Morton's neuroma: a review of recent concepts.

Orthopedics 1987;10(1):103-6.

13. Morscher E, Ulrich J, Dick W. Morton’s intermetatarsale neuroma: morphology and

histological substrate. Foot Ankle Int 2000;21(7):558–62.

14
14. Weinfeld S, Myerson M. Interdigital neuritis: diagnosis and treatment. J Am Acad Orthop Surg

1996;4:328–35.

15. Jones JR, Klenerman L. A study of the communicating branch between the medial and lateral

plantar nerves. Foot Ankle 1984;4(6):313-5.

16. Diez EM, Mas SM, Pi JF, Aramburo F. Comparative results of two different techniques in the

treatment of the Morton's neuroma. The Foot 1999;9(3):134–7.

17. Bennett GL, Graham CE, Mauldin DM. Morton's interdigital neuroma: a comprehensive

treatment protocol. Foot Ankle Int 1995;16(12):760-3.

18. Lassmann G. Morton’s toe: clinical, light, and electron microscopic investigations in 133

cases. Clin Orthop Relat Res 1979;142:73–84.

19. Kim JY, Choi JH, Park J, Wang J, Lee I. An anatomical study of Morton's interdigital neuroma:

the relationship between the occurring site and the deep transverse metatarsal ligament

(DTML). Foot Ankle Int 2007;28(9):1007-10.

20. Quinn TJ, Jacobson JA, Craig JG, van Holsbeeck MT. Sonography of Morton's neuromas. AJR

Am J Roentgenol 2000;174(6):1723-8.

21. Levy M, Seelenfreund M, Maor P, Fried A. [Post-traumatic Morton's neuroma]. Harefuah

1972;83(5):202-3.

22. Litchman MH, Silver CM, Simon SD. Morton's metatarsalgia and its relationship to trauma. R i

med j 1964;47:328-31.

23. Giannini S, Bacchini P, Ceccarelli F, Vannini F. Interdigital neuroma: clinical examination and

histopathologic results in 63 cases treated with excision. Foot Ankle Int 2004;25:79–84.

24. Coughlin MJ. Common causes of pain in the forefoot in adults. J Bone Joint Surg Br

2000;82:781–790.

15
25. Mulder JD. The causative mechanism in Morton's metatarsalgia. J Bone Joint Surg Br

1951;33:94–5.

26. Claassen L, Bock K, Ettinger M, Waizy H, Stukenborg-Colsman C, Plaass C. Role of MRI in

detection of Morton's neuroma. Foot Ankle Int 2014;35(10):1002-5.

27. Mahadevan D, Venkatesan M, Bhatt R, Bhatia M. Diagnostic Accuracy of Clinical Tests for

Morton's Neuroma Compared With Ultrasonography. J Foot Ankle Surg 2015;54(4):549-

53.

28. Pastides P, El-Sallakh S, Charalambides C. Morton's neuroma: A clinical versus radiological

diagnosis. Foot Ankle Surg 2012;18(1):22-4.

29. Read JW, Noakes JB, Kerr D, Crichton KJ. Morton’s metatarsalgia: sonographic findings and

correlated histopathology. Foot Ankle Int 1999;20:153–61.

30. Bencardino J, Rosenberg ZS, Beltran J, Liu X, Marty-Delfaut E. Morton’s neuroma: Is it always

symptomatic? Am J Roentgenol 2000;175:649–53.

31. Lee MJ, Kim S, Huh YM, Song HT, Lee SA, Lee JW, et al. Morton neuroma: evaluated with

ultrasonography and MR imaging. Korean J Radiol 2007;8(2):148-55.

32. Sharp RJ, Wade CM, Hennessy MS, Saxby TS. The role of MRI and ultrasound imaging in

Morton's neuroma and the effect of size of lesion on symptoms. J Bone Joint Surg Br

2003;85(7):999-1005.

33. Symeonidis PD, Iselin LD, Simmons N, Fowler S, Dracopoulos G, Stavrou P. Prevalence of

interdigital nerve enlargements in an asymptomatic population. Foot Ankle Int

2012;33:543–7.

34. Torres-Claramunt R, Ginés A, Pidemunt G, Puig L, de Zabala S. MRI and ultrasonography in

Morton's neuroma: Diagnostic accuracy and correlation. Indian J Orthop 2012;46(3):321-

5.
16
35. Xu Z, Duan X, Yu X, Wang H, Dong X, Xiang Z. The accuracy of ultrasonography and magnetic

resonance imaging for the diagnosis of Morton's neuroma: a systematic review. Clin Radiol

2015;70(4):351-8.

36. Greenfield J, Rea J Jr, Ilfeld FW. Morton's interdigital neuroma. Indications for treatment by

local injections versus surgery. Clin Orthop Relat Res 1984;185:142-4.

37. Schon L. An injection of corticosteroid plus anesthetic was more effective than anesthetic

alone for Morton neuroma. J Bone Joint Surg Am 2014;96(4):334.

38. Rasmussen MR, Kitaoka HB, Patzer GL. Nonoperative treatment of plantar interdigital

neuroma with a single corticosteroid injection. Clin Orthop Relat Res 1996;326:188–93.

39. Markovic M, Crichton K, Read JW, Lam P, Slater HK. Effectiveness of ultrasound-guided

corticosteroid injection in the treatment of Morton's neuroma. Foot Ankle Int

2008;29(5):483-7.

40. Makki D, Haddad BZ, Mahmood Z, Shahid MS, Pathak S, Garnham I. Efficacy of corticosteroid

injection versus size of plantar interdigital neuroma. Foot Ankle Int 2012;33(9):722-6.

41. van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg

following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg

2016;22(2):139-41.

42. Gaynor R, Hake D, Spinner SM, Tomczak RL. A comparative analysis of conservative versus

surgical treatment of Morton's neuroma. J Am Podiatr Med Assoc 1989;79(1):27-30.

43. Jabbari B, Machado D. Treatment of refractory pain with botulinum toxins—an evidence-

based review. Pain Med 2011;12(11):1594-606.

44. Díaz-Llopis IV, Rodríguez-Ruíz CM, Mulet-Perry S, Mondéjar-Gómez FJ, Climent-Barberá JM,

Cholbi-Llobel F. Randomized controlled study of the efficacy of the injection of botulinum

17
 toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six

months. Clin Rehabil 2012;26(7):594-606.

45. Argoff C. The emerging use of botulinum toxins for the treatment of neuropathic pain. Pain

Med 2010;11(12):1750-2.

46. Aoki KR. Review of a proposed mechanism for the antinociceptive action of botulinum toxin

type A. Neurotoxicology 2005;26(5):785-93.

47. Climent JM, Mondéjar-Gómez F, Rodríguez-Ruiz C, Díaz-Llopis I, Gómez-Gallego D, Martín-

Medina P. Treatment of Morton neuroma with botulinum toxin A: a pilot study. Clin Drug

Investig 2013;33(7):497-503.

48. Fanucci E, Masala S, Fabiano S, Perugia D, Squillaci E, Varrucciu V, et al. Treatment of

intermetatarsal Morton's neuroma with alcohol injection under US guide: 10-month

follow-up. Eur Radio. 2004;14(3):514-8.

49. Musson RE, Sawhney JS, Lamb L, Wilkinson A, Obaid H. Ultrasound guided alcohol ablation of

Morton's neuroma. Foot Ankle Int 2012;33(3):196-201.

50. Hughes RJ, Ali K, Jones H, Kendall S, Connell DA. Treatment of Morton's neuroma with

alcohol injection under sonographic guidance: follow-up of 101 cases. AJR Am J

Roentgenol 2007;188(6):1535-9.

51. Gurdezi S, White T, Ramesh P. Alcohol injection for Morton's neuroma: a five-year follow-up.

Foot Ankle Int 2013;34(8):1064-7.

52. Yap LP, McNally E. Patient's assessment of discomfort during ultrasound-guided injection of

Morton's neuroma: selecting the optimal approach. J Clin Ultrasound 2012;40(6):330-4.

53. Pasquali C, Vulcano E, Novario R, Varotto D, Montoli C, Volpe A. Ultrasound-guided alcohol

injection for Morton's neuroma. Foot Ankle Int 2015;36(1):55-9.

18
54. Ata AM, Onat ŞŞ, Özçakar L. Ultrasound-Guided Diagnosis and Treatment of Morton's

Neuroma. Pain Physician 2016;19(2):E355-8.

55. Morgan P, Monaghan W, Richards S. A systematic review of ultrasound-guided and non-

ultrasound-guided therapeutic injections to treat Morton's neuroma. J Am Podiatr Med

Assoc 2014;104(4):337-48.

56. Mahadevan D, Attwal M, Bhatt R, Bhatia M. Corticosteroid injection for Morton's neuroma

with or without ultrasound guidance: a randomised controlled trial. Bone Joint J 2016;98-

B(4):498-503.

57. Genon MP, Chin TY, Bedi HS, Blackney MC. Radio-frequency ablation for the treatment of

Morton's neuroma. ANZ J Surg 2010;80(9):583-5.

58. Moore JL, Rosen R, Cohen J, Rosen B. Radiofrequency thermoneurolysis for the treatment of

Morton's neuroma. J Foot Ankle Surg 2012;51(1):20-2.

59. Deniz S, Purtuloglu T, Tekindur S, Cansız KH, Yetim M, Kılıckaya O, et al. Ultrasound-guided

pulsed radio frequency treatment in Morton's neuroma. J Am Podiatr Med Assoc

2015;105(4):302-6.

60. Chuter GS, Chua YP, Connell DA, Blackney MC. Ultrasound-guided radiofrequency ablation in

the management of interdigital (Morton's) neuroma. Skeletal Radiol 2013;42(1):107-11.

61. Fridman R, Cain JD, Weil L Jr. Extracorporeal shockwave therapy for interdigital neuroma: a

randomized, placebo-controlled, double-blind trial. J Am Podiatr Med Assoc

2009;99(3):191-3.

62. Seok H, Kim SH, Lee SY, Park SW. Extracorporeal Shockwave Therapy in Patients with

Morton's Neuroma A Randomized, Placebo-Controlled Trial. J Am Podiatr Med Assoc

2016;106(2):93-9.

19
63. Wasserman G. Treatment of Morton's neuroma with the carbon dioxide laser. Clin Podiatr

Med Surg 1992;9(3):671-86.

64. Winckelbach JK. Use of Nd:YAG laser in the excision of Morton's neuroma. Clin Laser Mon

1993;11(7):103-4.

65. Drury AL. Use of homeopathic injection therapy in treatment of Morton's neuroma. Altern

Ther Health Med 2011;17(2):48.

66. Coughlin MJ, Pinsonneault T. Operative treatment of interdigital neuroma. A long-term

follow-up study. J Bone Joint Surg Am 2001;83-A(9):1321-8.

67. Womack JW, Richardson DR, Murphy GA, Richardson EG, Ishikawa SN. Long-term evaluation

of interdigital Neuroma treated by surgical excision. Foot Ankle Int 2008;29:574–7.

68. Thomson CE, Gibson JN, Martin D. Interventions for the treatment of Morton's neuroma.

Cochrane Database Syst Rev 2004;(3):CD003118.

69. McKeever DC. Surgical approach for neuroma of plantar digital nerve (Morton's

metatarsalgia). J Bone Joint Surg Am 1952;34-A(2):490.

70. Nery C, Raduan F, Del Buono A, Asaumi ID, Maffulli N. Plantar approach for excision of a

Morton neuroma: a long-term follow-up study. J Bone Joint Surg Am 2012;94(7):654-8.

71. Akermark C, Saartok T, Zuber Z. A prospective 2-year follow-up study of plantar incisions in

the treatment of primary intermetatarsal neuromas (Morton’s neuroma). Foot Ankle Surg

2008;14:67–73.

72. McElvenny RT. The etiology and surgical treatment of intractable pain about the fourth and

metatarsophalangeal joint (Morton’s Toe). J Bone Joint Surg 1943;25(3):675-9.

73. Faraj AA, Hosur A. The outcome after using two different approaches for excision of Morton's

neuroma. Chin Med J (Engl) 2010;123(16):2195-8.

20
74. Kundert HP, Plaass C, Stukenborg-Colsman C, Waizy H. Excision of Morton's Neuroma Using a

Longitudinal Plantar Approach: A Midterm Follow-up Study. Foot Ankle Spec 2016;9(1):37-

42

75. Richardson DR, Dean EM. The recurrent Morton neuroma: what now? Foot Ankle Clin

2014;19(3):437-49.

76. Glasoe WM, Coughlin MJ. A critical analysis of Dudley Morton's concept of disordered foot

function. J Foot Ankle Surg 2006;45(3):147–55.

77. Kasparek M, Schneider W. Transection of the deep metatarsal transverse ligament in

Morton's neuroma surgery does not increase risk of splayfoot development. Int Orthop

2016;40(5):953-7.

78. Dellon AL. Treatment of Morton's neuroma as a nerve compression. The role for neurolysis. J

Am Podiatr Med Assoc 1992;82(8):399-402.

79. Kubota M, Ohno R, Ishijima M, Hanyu R, Sakai K, Sugawara Y, et al. Minimally invasive

endoscopic decompression of the intermatatarsal nerve for Morton's neuroma. J Orthop

2014;12(Suppl 1) S101-4.

80. Zelent ME, Kane RM, Neese DJ, Lockner WB. Minimally invasive Morton's intermetatarsal

neuroma decompression. Foot Ankle Int 2007;28(2):263-5.

81. Shapiro SL. Endoscopic decompression of the intermetatarsal nerve for Morton's neuroma.

Foot Ankle Clin 2004;9(2):297-304.

82. Okafor B, Shergill G, Angel J. Treatment of Morton's neuroma by neurolysis. Foot Ankle Int

1997;18(5):284-7.

83. Villas C, Florez B, Alfonso M. Neurectomy versus neurolysis for Morton's neuroma. Foot

Ankle In. 2008;29(6):578-80.

21
84. Bauer T, Gaumetou E, Klouche S, Hardy P, Maffulli N. Metatarsalgia and Morton's Disease:

Comparison of Outcomes Between Open Procedure and Neurectomy Versus Percutaneous

Metatarsal Osteotomies and Ligament Release With a Minimum of 2 Years of Follow-Up. J

Foot Ankle Surg 2015;54(3):373-7.

85. Park EH, Kim YS, Lee HJ, Koh YG. Metatarsal shortening osteotomy for decompression of

Morton's neuroma. Foot Ankle Int 2013;34(12):1654-60.

86. Pace A, Scammell B, Dhar S. The outcome of Morton's neurectomy in the treatment of

metatarsalgia. Int Orthop 2010;34(4):511-5.

87. Bucknall V, Rutherford D, MacDonald D, Shalaby H, McKinley J, Breusch SJ. Outcomes

following excision of Morton's interdigital neuroma: a prospective study. Bone Joint J

2016;98-B(10):1376-1381.

88. Akermark C, Crone H, Skoog A, Weidenhielm L. A prospective randomized controlled trial of

plantar versus dorsal incisions for operative treatment of primary Morton's neuroma. Foot

Ankle Int 2013;34(9):1198-204.

89. Friscia DA, Strom DE, Parr JW, Saltzman CL, Johnson KA. Surgical treatment for primary

interdigital neuroma. Orthopaedics 1991;14(6):669-72.

90. Benedetti RS, Baxter DE, Davis PF. Clinical results of simultaneous adjacent interdigital

neurectomy in the foot. Foot Ankle Int 1996;17:264-8.

91. Stamatis ED, Myerson MS. Treatment of recurrence of symptoms after excision of an

interdigital neuroma. A retrospective review. J Bone Joint Surg Br 2004;86(1):48-53.

92. Lee KT, Kim JB, Young KW, Park YU, Kim JS, Jegal H. Long-term results of neurectomy in the

treatment of Morton's neuroma: more than 10 years' follow-up. Foot Ankle Spec

2011;4(6):349-53.

22
93. Su E, Di Carlo E, O'Malley M, Bohne WH, Deland JT, Kennedy JG. The frequency of digital

artery resection in Morton interdigital neurectomy. Foot Ankle Int 2006;27(10):801-3.

94. Wolfort SF, Dellon AL. Treatment of recurrent neuroma of the interdigital nerve by

implantation of the proximal nerve into muscle in the arch of the foot. J Foot Ankle Surg

2001;40(6):404-10.

95. Young G, Lindsey J. Etiology of symptomatic recurrent interdigital neuromas. J Am Podiatr

Med Assoc 1993;83(5):255-8.

96. Beskin JL, Baxter DE. Recurrent pain following interdigital neurectomy—a plantar approach.

Foot Ankle 1988;9(1):34-9.

97. Johnson JE, Johnson KA, Unni KK. Persistent pain after excision of an interdigital neuroma:

results of reoperation. J Bone Joint Surg Am 1988;70:651-7.

98. Adams SB Jr, Peters PG, Schon LC. Persistent or recurrent interdigital neuromas. Foot Ankle

Clin 2011;16(2):317-25.

99. Amis JA, Siverhus SW, Liwnicz BH. An anatomic basis for recurrence after Morton's neuroma

excision. Foot Ankle 1992;13(3):153-6.

100. Nelms BA, Bishop JO, Tullos HS. Surgical Treatment of Recurrent Morton's Neuroma.

Orthopedics 1984;7(11):1708-11.

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CAPTIONS

Fig. 1 – Subdivision of plantar nerves

Illustration showing the anastomotic branch from the common digital nerve for the fourth

interspace (branch from the lateral plantar nerve), to the common digital nerve to the third

interspace (branch from the medial plantar nerve). The interdigital nerve passes below the

corresponding intermetatarsal ligament, which is just proximal to the metatarsal heads, and then

divides into the two digital nerves. Morton's neuroma consists of a fusiform bulge in the

interdigital nerve just distal to the intermetatarsal ligament, and before the bifurcation in the

digital nerves.

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Fig. 2 – Dorsal approach

Illustration of longitudinal dorsal approach centered on the third interspace.

25
Fig. 3 – Plantar longitudinal approach

Illustration of longitudinal plantar approach centered on the third interspace.

26
Fig. 4 – Plantar transverse approach

Illustration of transverse plantar approach just proximal to the distal flexion skin fold, and extended

from fourth to second webspaces.

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Fig. 5 – Algorithm for clinical practice

28